UNITED STATES OF AMERICA *" * . FOUNDED 1836 WASHINGTON, D. C. GPO 16—67244-1 Atf Inaugural DifTertation on APOPLEXY. By THOMAS TRIPLETS of Alexandria BIA MEDICAL SC HONORARY MEMBER OF THE PHILADELPHIA MEDICAL SOCIETT f . Let others dilate, who themfelve^a^el^ &f And cenfure freely, who have writtem*jjjK~ PHILADELPHIA: PRINTED BY WAY & GROFF, No. »7, Arch-ftreet. I798. A N INAUGURAL DISSERTATION FOR THE DEGREE OF DOCTOR OF MEDICINE; SUBMITTED TO THE EXAMINATION OF THE Ref, JOHN WING, S, 5, T. P. Pxorosr; THE TRUSTEES ^ MEDICJL FACULTT, OF THE Univerfity of Pennfylvania, On the zzi day of May, 1798. hoq-hi 1,1 :>:iX*SM\ i TO WILLIAM SHIPPEN, M. D. Profejfor of Anatomyy Surgery and Midwifery : CASPAR WISTAR, M. D. Adjuntl Profejfor of Anatomyy Surgery and Midwifery } BENJAMIN RUSH, M. D. Profejfor of the Inflitutes and Clinical Medicine g BENJAMIN SMITH BARTON, M. D. Profejfor of the Materia Medicay Botany and Natural Hi/lory f JAMES WOODHOUSE, M. D. Profejfor of Chemiflry: AND TO MY PRECEPTOR, ELISHA GULLEN DICK, M. B. This Inaugural Dissertation is refpe&fully infcribed, as a tribute of gratitude and efleem, by their Sincere Friend and Affectionate Pupil, THOMAS TRIPLETT. AN INAUGURAL DISSERTATION, tsfe. JL HE Apoplexy, the fubject of the following Diflertation, is derived from the Greek word AirtvxMo-eu, which fignifies to ftrike fuddenly. It is commonly called Sideratio by Latinifts, and by the Englifh apoplexy, ftroke or blaftbg, becaufe, as Baron Van Swieten has obferved, perfons who are feized with it, " fall down at once as if ftruck by a fudden blow, in the fame manner as a bullock knocked down by a butcher's axe*" It is defined by Dr. Cullen, a fufpenfion or aboli- tion of almofl all of the external and internal fenfes, and all the voluntary motions, accompanied with fleep more or lefs profound, while refpiration, and the action of the heart and arteries ftill continue to be performed. It prevails moft frequently in thofe places and feafons of the year, which are moft fa- vourable to the produ&ion of inflammatory com- plaints, as in warm fprings, which have been pm ceded by very cold winters; or in winters which are not uniformly cold. ( 8 ) Between the years 1683 and 1687, apoplexies were fo common in Italy and many other parts of Europe, and fuch numbers are mentioned to have died of this difeafe, as render* it highly probable that it was epidemic** At thefe times the weather was uncommonly fevere,- fhe winters being much colder, and the fummers much hotter and drier than ufual. A juft idea may be formed of this, from the following paffage in a letter from Dr. Cole, Who wrote abouttmVperiod, and attributed the uncom- mon frequency of the difeafe, to the intenfely cold weather. " Now it is known, (fays he), f that the winter of the year 1683 (from which 1 date my era of this frequency of apoplexies) Was fo intenfely cold, and that cold of (6 long continuance, that no man's memory living could fupply him with a parallel year; and there was no need to repair to the northern region to make experiments of freez- irig fpirituous liquors", in order to find out the extent of this effect of it. Since which time it may be Obferved, that this difterriper has been fo rife** The difeafe continued'to prevail with great mortality till the year 169$-,- for during this time, Baglivi tells us, it fwept off great numbers all over Italy; the cstufe of whichj he attributes to the unufual conft*. tUtfon <5f the weather; the fummer of 1693 was extremely hot and fchorching, followed-by intenfely • Baglivius. De apoplex. epidem. &c. page 340. t Cole on the frequency of apoplexies, page 107 ( 9 ) Cold weather, and contrary to the cuftom of Italy, the fnow and ice were a foot deep in many parts of that country. The following fummer was exceffively hot and dry, for there was no rain for five months; add to thefe the univerfal grief occafioned by the war, which all Europe was at that time engaged in, the malignant exhalations from the earthquakes, together with a plague which raged in fome parts of Italy; all tended to produce the fatal apoplexies, which raged with fuch violence during this time. The apoplexy does^ however, certainly occur at all places, and at all feafons, fparing neither age nor fex, though males are more liable to it than females, and perfons who are beyond fixty years of age,* than thofe who have not arrived at that period. Very corpulent people, and efpecially thofe who have indulged too liberally in the pernicious life of fpirituous liquors, and who, from fome peculiari- ty of conftitution and make, as fhort necks and large heads, with extremely irritable f habits, are commonly the fubjeds of this diforder. It is very common in times of epidemics, and is often fud* denly excited by the contagion of the plague, yel- • Cullen's Pra&ice of Phyfic. f Vid. Kirkland on .Apop, page 18. B ( io ) low fever, &c. from which we may juftly conclude, that perfons who are carried off fuddenly during mortal epidemics, die of apoplexies. * It often accompanies the paroxifms of intermittents, and goes off with the remiffion of the fever, f This difeafe comes on fuddenly -y the perfon at- tacked falling immediately to the ground, deprived for the moft part of aH fenfe and motion. There is, however, fometimes a total lofs of motion iand fenfation on the one fide, while convulfive action takes place on the oppofite one at the feme time; and this privation of fenfation and motion on one fide only, fo frequently happened at the com- mencement of the fit, that Morgagni thought he could tell which fide of the brain had fuffered by knowing the manner in which the patient fell* During an apoplectic paroxifm, the face be- comes diftorted, the cheeks affume-a peculiar florid or livid hue j every member is rendered flaccid and relaxed, { and the intellectual functions are com- pletely fufpended; the veffels of the head and face are turgid and enlarged; an haemorrhage fome- times takes place from the eyes, nofe, and ears, which affords fome temporary relief to the patient. The eyes are frequently half-opened, and of a glaf- fy appearance; they often pour forth an uncom- * Rufh's Lc&urej. -J- Barton's Le&ure*. J Hoffman, page 45$. C » ) mon quantity of tears : the fkin is fpmetimes dry and hot, owing to a dimininution of the cutaneous excretion. The mufcles of the lower jaw are great- ly relaxed j it falls, and the tongue is protruded between the teeth. Some authors* take notice of a plentiful vifcid foam at the mouth, which, when it does happen, fhews a great determination of blood to the head, and indicates much danger. At the commencement pf the paroxifrn, an invo- luntary difcharge of urine and faeces fometimes takes place, though there is often a preternatural retention of thefe excretions, The refpjration is performed with much difficulty, attended with a peculiar ftertorous noife., which may be afcribed to the air, being interrupted in its paf- fage to and from the lungs by an unufual accumu- lation of mucus and faliva in the mouth and nofe ; or by an extremely relaxed palatum molle. The pulfe is frequently at firft, full, tenfe and flow, f and fometfmes uncommonly foft. About the clofe of the4ifea(e it becomes languid, fmall, and feeble, A violent and rapid palpitation of the heart is not an.unftecment attendant on the difeafe, efpecially at the beginnings and fhews its great danger and violence. • Van Swieten Com. .Boerh. ^Vph.,»flL.lp. f There have been ,inftance.s,of the pulfe being .fodepreffed and Aqw, as to beat cnly feven flrokes in the minute. ( 12 ) The apoplexy generally terminates in death, in another difeafe, or in health j the laft, unhappily, does not very often happen. It is frequently fuc- ceeded by a palfy of fome particular part of the body, and lofs of fome internal fenfes, as the me- mory, &c.; and laftly, when death happens, it is preceded by convulfions, cold fweats, and other dangerous fymptoms, which we fhall take notice of hereafter. The idea that a third fit muft necef- farily prove fatal, is entirely erroneous, and, as pro- ductive of much mifchief and diftrefs, mould be exploded. Although this difeafe generally attacks fuddenly, yet it is fometimes preceded by certain harbingers, or precurfory fymptoms, which indicate its ap- proach ; thefe are, a pain in the head, and a fenfe of fulnefs in the veffels; a dulnefs or inactivity of bodily motion; diminifhed fenfation in the extre- mities j a noife in the ears called Tinnitus Auri- um, and fometimes a partial lofs of hearing and feeing. Perfons fubject to apoplexy have, during fleep, frequent fits of incubus, or the night hag, and are much djfturbed by frightful dreams, which may be owing to the languid or difficult circulation of the blood through the veffels of the brain : tre- mors ; a ftridor dentium or grinding of the teeth ; and laftly, if the patient had previoufly been fub~ ject to the hemorrhoids, an unufual abfence of ( IJ ) that complaint, may all be confidered as premoni-, tory of an attack. DIAGNOSIS. Since the fcience of medicine has been fo great- ly illumined by the indefatigable labors of Dr. Rufh, the diagnofis of difeafes is juftly confidered of much lefs importance than formerly. The abi- lities of that phyfician muft indeed be contemptible, who, inftead of the pulfe and condition of the fyf- tem, has recourfe to books of Nofology, and is im- plicity guided in his prefcriptions by the name of a difeafe. As, however, in the one under consi- deration, from its great violence and fpeedy termi- nation, it becomes a matter of the utmoft import- ance to have immediate recourfe to the moft power- ful and effectual remedies ; and as it might not only be a fource of much difgrace to the practitioner, but injurious to the patient, to prefcribe thefe re- medies when there was no neceffity; it may not be improper to fay fomething of thofe figns by which this difeafe may be diftinguifhed from all others. Many of the appearances which drunkennefs ex- hibits, are fo fimilar to the apoplexy, that it is at firft extremely difficult to afcertain the difference between them. The pallid countenance of the in- ( 14 ) ebriate, together with the fumes of the liquors which he has taken in, have been confidered as fufficient to direct us. But intoxication is often produced by malt liquors, as porter and beer, which renders the difficulty ftill greater. Here we muft draw conclufions from the hiftory of the patient's fituation: the face of an apoplectic patient is more puffed up, and the refpiration is more laborious than in thofe who are drunk. This difeafe may, according to Dr, Cullen, be very readily diftinguiflied from palfy, by the fuf. penfion of the whole of the powers of fenfe and jaotion: in the palfy thefe are only partially affect- The coma which fucceeds the epilepfy, refem- foles very much a fit of apoplexy, but differs from k by being preceded by convulfions. la a perfect fyncope, the heart and arteries ceafe to act; hence it is eafily diftinguiflied from apo- plexy. There are a number of difeafes under the deno- minations of cams, cataphora, lethargus, &c. and require nearly the fame treatment; it is therefore unneceuary to draw accurate diftinctious between them. ( '5 ) All thefe morbid ftates of the fyftem are grade* of apoplexy. An apoplectic paroxifm may gene- rally be diftinguifhed from a found fleep, by coming on fuddenly, and without any previous fatigue; alfo by the difficulty of roufing the patient. This laft, however, fhould not always determine tis, for men are fometimes fo exhau'fted by labour ot Watching, that the loudeft noife has no effect in waking them. Van Swieten relates the cafe of a warrior, who, after having had no fleep for forty- eight hours, wrapped himfelf in his cloak, and laid down on the ground, between two cannon that were firing continually; yet neither the noife of the foldiers, nor the conftant and terrible, roaring of thefe cannons, Were fufficient to roufe him from a pleafant fleep, wnieh he enjoyed for ten hours.1* REMOTE CAUSES. Under this head authors have generally com- prehended the predifpofmg and occafional or excit- ing caufes. Accordingly we fhall proceed to con- fider them in this order. As the predifpofing caufe of apoplexy appears to be debility, and this moft frequently of the indirect kind, exifting in a great- er degree in the brain than in any other part, we fhall firft treat of fuch caufes, as, by producing a * Van Swieten Com. Boer. Aph. vol. io< ( i6 ) general plethora of the fyftem and fullnefs in the veffels of the brain, induce debility, and confe- quently difpofe to apoplexy. Among this number, a generous ftimulating diet muft have the effect of predifpofing to the difeafe, by producing a large quantity of chyle, and confequent increafe in the general mafs of fluids. i. Indolence, and excefs in eating and drinking, produce a plethoric ftate of the fyftem, and by diftending the ftomach and interrupting the func- tions of refpiration, prevent the free return of blood to the heart; hence the countenances of thofe who indulge too freely in fuch exceffes be- come florid and turgid with blood ; they become ftupid and fleepy; and numberlefs inftances have occurred where they have dropped from their chairs in an apoplectic paroxifm. 2. Corpulency, is another very powerful caufe, for here preffure is applied to all the veffels of the body, except the brain, and this being deftitute generally of fat, the blood becomes accumulated there j and upon any unufual exertion, as run- ning, jumping, ftooping, &c. the veffels are liable to be ruptured. In corpulent perfons, refpiration is performed with difficulty; and this occafions an impediment in the return of the blood from the ( «7 ) brain, which rnuft confcquently predifpofe to apo* plexy* 3. The fuppreflion of any ufual evacuation, fuch as the hemorrhoids, menftrual difcharge, or an habitual bleeding at the nofe, all tend to increafe the plethora of the fyftem, and in this way pro* duce a predifpofition to the difeafe* 4. Long and conftant application of the mind on one fubject, by increafing the determination to the brain, predifpofes to apoplexy. 5. Old age. A greater number of "perfons die of this difeafe after the meridian of life than be* fore. Perhaps this predifpofition in old people to apoplexy, may be afcribed to a venous plethora, and alfo an accumulation of their excitability. 6. I might go on to enumerate a variety of ©ther caufes that induce a Mate of the fyftem predifpofing to this difeafe, among which are reckoned certain forms of the body, as a preternaturally fhort neck and large head, &c* but having already mention^ ed fuch as moft commonly occur, and fliould be particularly attended to in avoiding or preventing an attack, I fhall now take notice of fome of thd exciting caufes. C ( i8 ) EXCITING CAUSES. Among thefe, may be confidered all fuch, as when generally or partially applied to the fyftem, efpeci- ally when labouring under great predifpofition, ate capable of producing the phenomena of difeafe, which may be effected by firft increafing the velocity of the blood in the general circulation, and conse- quently in the veffels of the brain, or fecondly, by impeding the blood in its paffage from the head, and thus producing an accumulation and congeftion there: Of this number, i. A large undigefted meal* may be confidered as the moft frequent; for by diftending the ftomach, preventing in a great meafure the expanfion of the lungs, and preffing upon the aorta, it accumulates the blood in the veffels of the brain, and proves a very frequent fource of this difeafe. 2. Heat, whether generally or partially applied to the body, is a powerful exciting caufe : numbers are related by Tiffotf to have perifhed of apoplexies from imprudent expofure to the rays of the fun. 3. Stooping or laying with the head too low, by favouring the flow of blood to the head, and by hindering its return. • Fothergill, page HO. f Treatife on Health. ( '9 ) 4. Ligatures, tumors, &c. about the neck or other parts of the body, by interrupting the free circulation of blood through the veffels of the head, tend to excite the difeafe. 5. Violent exercife, by increafing the general cir- culation, and accelerating the flow of blood to th3 brain, will often have the fame effect. 6. Contufions and fracture* of the cranium. 7. The fuddcn ftriking in of eruptions, drying up of iffues, featons, &c. may all prove exciting caufes of apoplexy, either by increafing the action of the veffels or the quantity of the circulating fluids. 8. Any confiderable impediment to the free paf- fage of the blood from the Teins to the right auricle of the heart j in which way, polypus concretions in the cava, are found to occafion the apoplexy, 9. Vomiting. Any caufe which has the effect of impeding the circulation through the lungs, and thus interrupting the free paffage of blood to the heart, tends to excite a paroxifm of this difeafe, and it is in this way that vomiting appears to a&: during the violent and continued exertions to vomit, the blood is prevented from pafling freely to the ( *0 ) right auricle, and thus it becomes accumulated in the veffels of the head; hence, the face and neck fwell and affume a florid colour, and the eyes are fuffufed with blood. 10, Hot bathing is a frequent caufe of apoplexy. u. Certain incitants or ftimulants, as opium, belladona, alchohol, &c. alfo the carbonic acid, or fixed air, have the effect of exciting this difeafe, 12, Contagion, as that of the plague, yellow- fever, &c. which I formerly took notice of as fre- quently producing apoplexies; the fumes of mercury and lead, are likewife faid to bring on this dreadful malady. 13. The ftimulating paflions are a fruitful fource of this difeafe ; hence Armftrong juftly obfenres, " He whom anger ftings, drops, if he dies, " At once, and rufhes apoplectic down," 14. Intenfe thought, long and loud converfa^ tions, and laftly exceflive venery, have all excited a paroxifm of apoplexy, by hurrying the circula- tion, and determining the blood to the brain. ( « ) APPEARANCES on DISSECTION. Previous to treating of the proximate caufe of apoplexy, it may not be improper to fay fomething of the appearances after death. From phenomena difcovered by diffections, the healing art has been greatly enriched, and it is from thefe, together with a faithful attention to the fymptoms in living bodies, that phyficians have been enabled to form correct conclufions with refpect to difeafes. Among the number who have contributed by their labours to elucidate this branch of the fcience, the celebrated Morgagni appears to deferve the higheft attention. I fhall felect from amongft the various phenomena, which he has noticed, fuch as appear from their fre- quent occurrence, to be of the greateft application to practice. Upon examining the brains of num- bers, who have died with this difeafe, he difcovered a quantity of extravafated blood between the cra- nium and dura mater, and in the ventricles; blood was Hkewife often found in almoft every cavity of the brain; from which circumftance Hoffman con- cluded that this was always the cafe, and denomi- nated the difeafe hemorrhagia cerebri. Pus was fometimes found in thefe cavities and ventricles, though rarely, and the fubftance of the brain hac been found more flaccid and foft than ufual; large portions of it are fometimes corroded, probably from the putrid ftagnant blood. The blood-veffels ( a* ) are frequently very much diftended, efpecially thofe of the plexus choroides; and little vefficles or hy- datids, were found in conjuction with this membrane. Large quantities of bloody ferum are often effufed in the cavities of the brain, and fometimes the branches of the carotid artery are lacerated. An enlarged pineal gland has now and then been difcovered, and thought by fome to produce the apoplexy. Mr. Chefelden has furnifhed us with the diffec- tion of a man who died of this diforder, and which throws much light upon the fubject. " I found," fays he,* " all the veffels of the brain immoderately diftended with blood, and the ventricles and fub- ftance of the brain full of lymph; the pia-mater much thickened, and adhering fo very loofely, that the greater part of it was feparated without break- ing." PROXIMATE CAUSE. NO part of the fcience of medicine has more at- tracted the particular attention of phyficians than the proximate caufe of difeafes, and perhaps on no fubject has there been advanced a greater contrariety of opinions than on the prefent. Were it not for the implication of prefumption, in objecting to a term in medicine which has fo long received the * Anatomy, page **5- ( n ) fanction of the moft celebrated characters, I mould be led to reject the term proximate caufe, as entirely fuperfluous,if not,in its ufualacceptation, erroneous; for why mould we call that a caufe, which is in fact, no other than an effeft, or in other words the difeafe itfelf. Hoffman, thinking this difeafe depended upon hemorrhagy, gave it the fame proximate caufe as other hemorrhagies, and fuppofed the fymptoms might be accounted for, by the preffure which is made upon the brain, difturbing both the motion of the nervous fluid, and the circulation of blood. Whilft Dr. Cullen fuppofed whatever interrupted the flow of nervous power to the mufcles of volun- tary motion, or deftroyed the mobility of that power, to be the proximate caufe of this difeafe j he alfo admitted the diftinction of ferous and fanguine- ous apoplexies, though he fuppofed it could not be ufefully applied to practice, as both kinds might often depend upon a venous plethora, and thus require the fame treatment. Certain it is, that effufions of ferum or red blood may happen alike to all, and there is no method of afcertaining upon which the difeafe depends but by diffections. The impropriety, therefore, of this divifion, muft be at once evident; and as it might lead us to an improper method of cure, fhould no longer be admitted. According to Dr. Rufh, the proximate caufe of apoplexy is ( 24 ) preternaturally accumulated excitement in the brain, which is fo great as fuddenly to deftroy the action of the veffels; and thus they become diftended with blood, for not being able to react and propel their contents, they are either greatly enlarged, or their fmaller branches are ruptured; hence the effu- fions which take place are merely the effects of this preternatural excitement, and not the caufe as has been fuppofed. In order, however, to produce the phenomena of the difeafe, the preffure (either from a dilatation of the veffels, or from effufions) muft be fuddenly applied to the brain; for it ap- pears not to have the fame effects when gradually brought on, as we have many inftances of the heads of children being enlarged to twice or thrice their ufual fize in the hydrocephalus internus,* where the brain muft have been greatly compref- fed, and yet all its functions have gone on with little or no interruption. I fhall, therefore, adopt Dr. Rufh's theory of the proximate caufe of apo- plexy, namely, preternaturally accumulated excite- ment, as one which appears to me to be lefs excep- tionable, and which will better explain the pheno- mena of the difeafe than any hitherto advanced. PROGNOSIS. The apoplexy comes on with fuch violence and at times fo very fuddenly, that it often proves fatal, Do&or Willar'i J»e&ure«» When this does not happen, it is accompanied with fuch a variety of fymptoms, that it would be im- prudent in a phyfician to determine at once in what manner it would terminate. It is, however, an ob- ject of fome concern both to the relations and pa- tient, to know the event> and, in endeavouring to form a juft prognofis, we fhould always take into confideration,the age, conftitution, and ftrength of the patient, the violence of the caufes which have induced the difeafe, and laftly^ its fymptoms. With due regard to thefe circumftances, the phyfi- tian may always be enabled to draw accurate con- clufions* When the patient is young, poffefling a found and otherwife healthy conftitution, if his ftrength has not been confiderably exhaufted by the continuance Of the difeafe, arid if the coma and lofs of motion do not continue long, there may be fome propriety in concluding in favour of a recovery. When the apoplexy has been brought on by the fuppreffion of fome ufual evacuation, as the hemorrhoids, menftrual difcharge, or bleeding at the nofe, a return of thefe, either naturally or artificially, may be confidered as falutary. A warm and equally diffufed perfpiration over the whole furface of the body; a copious difcharge of urine depofiting a fediment, or an evacua- tion from the bowels, are all favourable fignsj and have produced a refolution of the difeafe; but when, on the contrary, the patient is old and infirm, his ftrength nearly exhaufted, and D ( 26 ) the caufes inducing the difeafe violent, there can be but little hopes of a recovery. When the fymp- toms, fuch as lofs of motion and fenfes, continue accompanied with profound fnoring, a vifcid foam at the mouth, lofs of deglutition, and, above all, an involuntary difcharge of faeces and urine upon the commencement of the fit, great danger is to be apprehended. If the pulfe be preternaturally flow and depreffed, or irregular, feeble, and fre- quent, and the patient's countenance affumes a cadaverous afpect, there can be but little doubt of the near approach of dealh. THE METHOD OF CURE. When a perfon has once been fo unfortunate as to be feized with a paroxifm of this direful ma- lady, though he may evade the hand of death for the time, yet his conftitution fuffers greatly by it. He not only becomes fubject fo vertigo, lofs of memory, defective fight, and an innumerable train of ills attendant on his efcape from the grave, but alfo more obnoxious to the difeafe. Unhappily, however, it too feldom happens that he is bleffed with even this fmall portion of life; for the difeafe comes on generally with fuch fury, that it foon produces diforganization of the brain, and unlefs the moft judicious remedies are fpeedily employed, he falls a victim to its ravages. In treating of the cure of apoplexy, we fhall firft confider thofe re- ( *7 ) medies which are moft proper to be ufed during the continuance of a paroxifm; and fecondly, what are the beft methods to be obferved for pre- venting its return. It is of the utmoft importance in the commence- ment of the fit, immediately to diminifh the ex- citement of the veffels of the brain, and thus pre- vent the congeftion, and confequent effufions: with this intention, copious bleeding is to be em- ployed. Various ways have been recommended for drawing the blood immediately from the head ; for this purpofe fome have advifed opening the temporal and carotid arteries, the veffels under the tongue, &c. Others have thought, that every advan- tage might be derived by drawing it from the jugu- lar veins, or from both arms at once. The former of thefe methods, as attended with fome danger, may with propriety be laid afide ; an objection may Hkewife be ftart^d againft operating on the jugular veins, as it is frequently neceffary to apply a liga- ture about the neck; which might have the effect of rupturing the veffels already greatly diftended. Every intention may, I believe, be fufficiently an- fwered by opening the veins in one or both arms. In this way a fufficient quantity of blood may be drawn ; befides, the blood fliould not be too fud- denly taken away ; for when gradually drawn, the veffels which had been fo greatly dilated as almoft to lofc the power of contraction, accommodate ( ,8 ) themfelves to their contents, and thus are enabled to react and propel the ftagnant blood. The quantity to be taken at a time, fhould be regulated by the urgency of the fymptoms and condition of the fyftem. Perhaps we may be juftified in draw- ing more blood in difeafes of the brain, than in any others ; for here, as Dr. Rufh has juftly remarked, there is no out-let for the veffels to relieve them- felves ; but in affections of many other parts of the body, as the lungs for inftance, the veffels are re- lieved by effufions into the bronchiae. Dr. Cole, * who wrote upwards of one hundred years ago, fays, he often took from thirty to fixty ounces of blood at once in an apoplexy, and recommended this practice in the higheft terms, f Bleeding is al- ways more neceffary where the difeafe has come on without much predifpofing debility. Mr. John Hunter has obferved, that in difeafes of the brain, the pulfe is much lefs to be depended upon than in almoft any other diforder; hence, in this difeafe, we fhould take into confideration all the other cir- cumftances which might lead to a judicious appli- cation of this remedy. It is in the lefs violent apo- plexy, fays Pr. Rufh, that we find a full and * Cole on frequency of Apoplexy, page 173, f A phyfician, in the city of Philadelphia, had upwards of ninety ounces of blood taken from him atone time, in an apoplectic patoxifm ; by which he was fo fpeedily reftoied, as tq be able to vifit his patients in a few days after, and now enjoys the moft perfect health. When we re- flect, that in a healthy man, there are from «J to 35 lbs. of blopd. this practice will not appear fo ralh as at firft might be coiifideried, ( 29 ) tenfe pulfe; and hence, a fever fupervening, may always be confidered fas a good fign. The cold- nefs of the extremities, the preternaturally flow, or foft and languid pulfe, are all owing to the great preffure induced by the partial accumulated excitement in the brain, and, inftead of forbidding the lancet, call more loudly for its ufe. * If after bleeding has been carried as far as the exifting cir- cumftances feem to admit, and the fymptoms ftill continue, cupping and fcarifications of the neck and temples, may be highly advantageous, and fhould not be omitted. 2. Purging. The bowels fhould always be kept regularly open, as a coftive habit tends to aggravate all the fymptoms of the difeafe: we fhould make ufe of fuch medicines for this purpofe as will act brifkly, though the more draftic purges are not to be pre- ferred. Hoffman relates the cafe of a perfon in whom an apoplexy was excited by the operation of an acrid cathartic. If the patient has entirely loft the power of deglutition, acrid ftimulating injections fhould be thrown into the rectum; they have the effect of relieving the bowels, and by exciting a degree of irritation and inflammation in the rectum, invite the morbid action to the part, and thus dirai- nifh the excitement in the brain. 9. Cold water. When the difeafe has been bro*t on by breathing carbonic acid gas, or by expofure • Dr. Rufti's Lectures. C 3° ) to heat, this remedy appears to be particularly fcr- viceable. It is a very powerful means of diminifli- ing the excitement of the veffels, and fhould be applied immediately to the head. TilTot * relates ' the cafes of feveral perfons who were cured of apo- plexies, (brought on by imprudent expofure to the rays of the fun,) by putting them into a Lath almoft as cold as ice. 4. Cool and frefh air. Where the apoplexy has been brought on by breathing impure air in crouded affembles, &c. we fhould immediately expofe the patient to pure, cool air; for this purpofe, a crowd of people fhould always be prohibited from furround- ing him, as is too frequently the cafe : he fhould be placed in an erect pofture if poflible, and all band- ages, efpecially about the neck, ought to be fpee- dily removed, 5, Emetics can feldom be exhibited with advan- tage, except where the difeafe has been excited by , fome poifonous or indigeftible fubftances received into the ftomach : here they may be highly proper if early adminiftered; but when this is neglected, they are of little fervice; and as they often do harm, other remedies ought to be preferred. What we have already faid of them, when treating of the exciting caufes, is fufficient to deter us from their indiforiminate ufe. • Trcatife on Health, page 174, ( 3> ; 6. The ufe of the fedative paffions, may be of much fervice when they can be employed : fear has cured the temporary apoplexy, induced by in- toxication. 7. Blifters fhould be applied to the head and neck. The head ought previoufly to be fhaved, and the blifter fhould be large enough to nearly cover it: they impart but little ftimulus to the fyf- tem, and their good effects here feem to be owing to the evacuation immediately from the part. If, after all thefe have been ineffectually adminifr tered, and the difeafe has continued for fome time, the fyftem may be now confidered as in a ftate of atony; and confequently a different method of cure fhould be purfued; for the remedies which we have recommended above, can feldom be proper where indirect debility has long exifted. Here we muft have recourfe to the moft ftimulating applications, as cataplafms compofed of garlic and muftard, &c. to the arms and feet; in this way they have had the good effect of roufing the patient. Electricity and frictions ought to be tried, and certain acrid fubftances, as garlic, held in the mouth, may be of much fervice. Ardent fpirits and the volatile falts fhould be given internally. If the ftupor, drowfinefs, and defect of memo- ry, ftill remain, featons and cauftics fhould be em* ( 3* ) ployed : they have often effected a cure, whert every thing elfe had failed. In order to prevent a return of this difeafe, great care fhould be taken to avoid all the exciting caufes. The patient fhould be temperate, but not too ab- ftemious. If much accuftomed to drinking fpiri- tuous liquors, they ought not to be laid afide too fuddenly : diluted Madeira wine is perhaps prefera- ble to any other drink, and fhould therefore be ufed. He fhould eat often, and but little at a time; and all indigeftible fubftances muft carefully be avoided, efpecially loading the ftomach juft before going to bed. t)rk Rufh thinks he has known good effects from eating garlick, in keeping off an attack of this dif- eafe : it appears to keep up the tone of the fyftem, without much increafing the action of the veffels, and is particularly ferviceable in the vertigo which fucceeds an apoplexy. If, after a proper attention to all thefe circumftances, the fymptoms of another attack fhould ftill come on, they muft be cured by gentle evacuations, and fuch remedies as are proper during the paroxifm, but in a leffer degree. THE END. Me-cL.Hist. wz A.70 T135L 1712 <: -l